Career Advice for Young Allergy Patients: A Systematic Review
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Background: One-third of all young persons entering the work force have a history of atopic disease. Occupationally induced allergy and asthma generally arise in the first few months on the job, while pre-existing symptoms tend to worsen. Young persons with a history of an atopic disease should receive evidence-based advice before choosing a career.
Methods: We systematically searched PubMed for cohort studies investigating the new onset of asthma, rhinitis, or hand eczema among job trainees from before the start of training and onward into the first few years on the job. The search revealed 514 articles; we read their abstracts and selected 85 full-text articles for further analysis. 24 of these met the inclusion criteria.
Results: According to present evidence, atopy and a history of allergic disease (allergic rhinitis, atopic dermatitis) are the main risk factors for occupationally induced disease. The predictive value of a personal history of allergic diseases for the later development of an occupationally induced disease varies from 9% to 64% in the studies we analyzed. It follows that only young people with severe asthma or severe atopic eczema should be advised against choosing a job that is associated with a high risk of allergy, e.g., hairdressing or working with laboratory animals. Young people with a history of other atopic diseases should be counseled about their individual risk profile.
Conclusion: In view of the relatively poor predictive value of pre-existing atopic disease, secondary prevention is particularly important. This includes frequent medical follow-up of the course of symptoms over the first few years on the job. If sensitization or allergic symptoms arise, it should be carefully considered whether exposure reduction will enable the apprentice to stay on the job.
Approximately one-third of adolescents aged between 14 and 17 years suffer from at least one atopic disease. The most common such diagnosis is allergic rhinitis (20%), followed by atopic dermatitis (16%), bronchial asthma (8%), and allergic contact eczema (6%) (1). As a result, every year in Germany approximately 170 000 young people with a history of atopic disease start an apprenticeship (1, e1). In many workplaces, they are exposed to allergens and irritants.
Due to the high prevalence of atopic diseases (history of IgE-mediated sensitization or manifest disease) and the common exposure to allergens and irritants at the workplace, asthma and dermatitis are among the most common occupational diseases in many industrialized countries (e2). Internationally, occupational exposure is responsible for approximately 16% of asthma cases (e3) and probably a high percentage of hand eczema cases in adults. There are more cases of disease exacerbated by exposure at work than new cases caused by the workplace (e4–e8). In Europe the incidence of occupational asthma has remained constant since 2007 (2). In 2014, a total of 26 058 cases of occupational skin or airway disease caused by chemicals or allergens were reported in Germany (e9). That year they were the third-most common type of recognized occupational disease, with 1161 cases, exceeded only by noise-induced hearing loss and asbestos-related diseases (e9). Part of the reason for the large difference between the numbers of reported and recognized cases is that in Germany an individual must cease the harmful work in order for such diseases to be recognized as occupational.
The incidence of diseases triggered by work is highest in the first 6 to 12 months of employment (3–10, e10–e18) and is correlated with the level and frequency of exposure. In addition, recent evidence suggests that work-related stress is also associated with asthma and allergies (e19).
Although individual, risk-related career advice would be an important step in preventing both early cessation of training and the development of occupational diseases, various studies show that few young people with prior atopic diseases take them into consideration when choosing an occupation, and that only 10% of these receive advice from a physician (11–13, e20–e23). Individual, risk-related career advice leads to better use of personal protective equipment (PPE) at work (12). This shows how important it is for young people with atopic diseases to receive evidence-based advice from a physician.
This article therefore aims to summarize the published data on risk factors for and the course of occupational asthma, rhinitis, and hand eczema in the first years of work and to use this data to develop strategies for evidence-based career advice.
A systematic search of the literature was performed in the PubMed database for the period from the beginning of 2011 onwards. The procedure followed is described in detail in the eBox.
For rhinitis and asthma, the position paper of the European Academy of Allergy and Clinical Immunology (EAACI) was used as the basis for selecting studies published before 2011 (14). It should be mentioned that this method entails the limitation that due to poor data quality (in particular, there were no unexposed groups) the authors of the position paper were able to make only expert-based recommendations, not evidence-based ones. For skin disorders, the literature search was expanded to cover the period from 1965 onwards.
This search strategy identified 908 articles, of which the authors viewed the titles. On this basis, 514 were selected for their abstracts to be viewed. Of these articles, 85 potentially suitable fulltexts were identified, of which 24 were considered relevant to this review.
Only 5 of the 15 publications concerning the airways presented the findings of prospective cohort studies in which individuals at the beginning of their careers had been observed before or from the beginning of exposure (6–10). These 5 also contained data on risk factors before the beginning of training (eBox, eTable 1). Two studies were conducted in the general population (6, 9); an additional study included a small, unexposed comparison group (8). A study by Acouetey et al. followed 251 bakery/pastry and hairdressing apprentices prospectively over 2 years, taking gnetic predictors of occupational asthma into account (10). One additional study was very small, with only 37 participants, and had a very short follow-up period, lasting only one year (7).
The other prospective cohort studies either examined the first years following the end of training (15) or did not exclusively recruit individuals at the beginning of their careers (16, 17). There were also 2 publications on a retrospective cohort (18, 19) and 5 case–control studies (20–24); some of the latter were part of the cohort studies already mentioned (20–22).
The findings of the EAACI position paper (14) and more recent studies can be summarized as follows: in 8 of these studies a history of atopy was a risk factor for asthma or respiratory symptoms (eTable 2). In 5 studies, a pre-existing sensitization to occupational allergens was identified as risk factor for respiratory symptoms (rhinitis and asthma). Three studies provided evidence that pre-existing bronchial hyperresponsiveness was associated in particular with subsequent onset of asthma or airway symptoms.
Only a few studies investigated further potential risk factors for the development of occupational asthma or exacerbation of existing asthma in the first years of work. These found that women were more frequently affected than men; active smoking and exposure to passive smoking at an early age were described as unfavorable prognostic factors.
Allergic rhinitis and typical occupational sensitization
As with asthma, pre-existing sensitization to ubiquitous allergens is the principal risk factor for occupational sensitization and new-onset allergic rhinitis (eTable 2). Occupational sensitization can either remain asymptomatic or lead to allergic rhinitis or to airway symptoms at work and subsequently to occupational asthma. The atopic march (from atopic eczema to allergic rhinitis and asthma) could not be confirmed in all cohort studies (25).
The 9 included publications on occupational skin diseases (eBox, eTable 3) showed history of atopic eczema (26, e24), a positive atopy score according to Diepgen et al. (27, 28, e17, e25), and wet work (4, 5, 27, 28, e26) to be the principal risk factors for occupational hand eczema (eTable 4). Various other indicators of atopic skin diathesis, such as history of flexural eczema or dry skin, were also risk factors for occupational hand eczema (27, e17, e27) (eTable 4). Only one study investigated evidence in clinical history of pre-existing contact allergies; it was associated with a significantly increased risk of onset of hand eczema (e17).
Diagnostic procedures were also investigated as predictors of occupational hand eczema. These included various skin function tests, some of which were found to be very sensitive (94%) regarding subsequent onset of hand eczema. However, these tests were judged unsuitable for clinical practice due to their poor specificity (24%) (e17).
In a few studies, the positive predictive values of individual risk factors for the development of occupational asthma, rhinitis, and hand eczema were calculated. They were found to be between 9 and 64% (Table 1).
Due to the high prevalence of atopic diseases and their possible consequences for patients and indirectly for society as a whole, career advice for young people predisposed to atopy is very important. The available literature gives only a small number of confirmed predictive factors; these include prior atopic diseases and asymptomatic sensitization to ubiquitous allergens.
Intuitively, one might conclude that all atopy and asthma patients should be excluded from occupations that entail relevant exposures. However, this can only be clearly recommended for patients with severe asthma or severe atopic eczema (e28). For other prior conditions, various studies show that this measure—quite apart from its ethical implications—would not be effective, because most individuals with atopy will not develop occupational asthma or rhinitis. For example, to prevent one case of occupational asthma, 3 to 10 atopy patients would have to be advised against work that entailed a risk (29, e29). In view of the high proportion of individuals with atopy in the general population, this is not useful as the sole basis for decisions in individual career advice. However, individuals who are specifically sensitized, before the beginning of training, to a substance found at the workplace that cannot reliably be avoided, and who develop specific symptoms (rhinitis, asthma, eczema) on contact with that substance, should be advised against pursuing the occupation in question.
In a German study (6), models for predicting an individual patient’s overall risk in the first years of employment were developed on the basis of epidemiological studies and made available online as a risk calculator (www.allergierisiko.de). The risk calculator shows clearly how strongly the individual risk of developing asthma in the first months of a high-risk occupation depends on other cofactors: in the absence of other risk factors for asthma, the risk factor atopy increases the risk of new-onset asthma by only 1.8 percentage points, from 0.5% to 2.3%. The risk calculator also indicates the following other risk factors for asthma:
- Female sex
- Higher socioeconomic status
- At least one parent with asthma or atopic dermatitis
- Exposure to passive smoking during puberty
- Not breastfed
- No siblings.
If a patient has all these other risk factors, the risk of new-onset asthma is 32% for individuals without atopy and 70% for those with atopy. Additional studies should investigate whether these predictions are reliable.
The available research indicates that rhinitis (e10, e30, e31) and hand eczema (26) are particularly likely to lead individuals to cease their occupation and avoid exposure. It is therefore advisable to examine young people with a risk profile for these conditions closely at the beginning of training in high-risk occupations, in order to begin appropriate secondary prevention such as early treatment and use of PPE promptly. This can prevent cessation of training and damage to health. Occupational physicians, and possibly also pulmonologists and dermatologists, are important partners in this. Young people with a risk profile in occupations such as those shown in Table 2 should be examined every 6 to 12 months during the first 2 years of training (14, e10, e32).
Recent studies indicate that monitoring programs and training measures can reduce the risk of occupational asthma (e2, e33–e36) and hand eczema (6–10). School-based interventions among high school–age students have shown that the use of virtual patients in the classroom can improve young people’s knowledge of occupational asthma and allergies in the long term (e37) (www.volle-puste.de). Training regarding skin protection and basic therapy in new workforce entrants has also been shown to be effective (e38). Without such measures, only around one-third of employees take preventive measures (e39). Secondary preventive measures, in contrast, do not seem to be as effective as complete avoidance of allergens (e40–e43). However, a recent study by Muñoz et al. was unable to confirm this (e44). It is important that thorough diagnostics be performed by a specialized physician before an individual is dismissed or hastily gives up his or her work. If occupational asthma is suspected, diagnostics should always also include patient self-monitoring of lung function for at least 3 weeks with and without occupational exposure (30). If allergic contact sensitization is suspected, epicutaneous tests should also be performed (e45).
The studies systematically summarized here show that the available data is rather scarce. In particular, there is a lack of long-term observational studies conducted in the general population and observing individuals from their choice of occupation through their first years of work. The studies conducted to date investigating high-risk occupations focused mainly on those working in occupations traditionally considered hazardous, such as nurses, hairdressers, animal laboratory employees, and bakers/pastry chefs. Very few studies included an unexposed comparison group. In addition, there is almost no research into non-occupational factors. Many of the available studies have methodological shortcomings such as excessively short follow-up periods, low participant numbers, or no appropriate statistical modeling.
The literature search was performed in the PubMed database only, as one would expect that being purely medical this subject would be addressed in publications listed in PubMed. Literature not published in journals was not viewed. It was only possible to include references in 4 languages. A few relevant studies may, therefore, not have been included. However, this would not have affected the outcome of the literature search significantly, as the findings of the available papers were generally consistent.
Approximately one-third of apprentices in Germany have an elevated risk of occupational asthma, allergies, and dermatitis. The individual predictive value of specific parameters is too low to advise all young atopy patients against entering particular occupations. Those with severe asthma or atopic eczema and clinically manifest sensitization that is relevant to certain occupations should avoid the occupations that entail a risk. All young atopy patients wishing to begin an occupation that entails a risk should be informed of the risk and of preventive measures beforehand and should be monitored every 6 to 12 months for the first 2 to 3 years after the beginning of exposure. In addition to allergy-specific history taking and general physical examinations, those with a history of allergies should receive skin prick tests for general and job-specific allergens, spirometry, and—in case of work-related respiratory symptoms—unspecific bronchial challenge tests (methacholine) (14). However, diagnostic testing for occupational allergy in patients without a history of allergic diseases (“prophetic testing”) is not indicated (e46).
The authors would like to thank the German Federal Ministry of Labor and Social Affairs for its funding for conduct of the SOLAR study, and the SOLAR study’s scientific panel for its advice.
Conflict of interest statement
Prof. Vogelberg was a member of various ALK-Abelló advisory boards.
Prof. Radon, Prof. Nowak, and Prof. Ruëff declare that no conflict of interest exists.
Manuscript received on 18 January 2016, revised version accepted on 14 April 2016.
Translated from the original German by Caroline Shimakawa-Devitt, M.A.
Prof. Dr. rer. biol. hum. Katja Radon
Center for International Health
Institute for Occupational, Social and Environmental Medicine
Munich University Hospital (LMU)
80336 München, Germany
For eReferences please refer to:
eBox, eTables, eFigure:
Comprehensive Pneumology Center, DZL, Deutsches Zentrum für Lungenforschung, München:
Prof. Dr. rer. biol. hum. Radon, Prof. Dr. med. Nowak
Department of Pediatrics, University Hospital Carl Gustav Carus, Dresden: Prof. Dr. med. Vogelberg
Department of Dermatology and Allergology, AllergieZENTRUM, Klinikum der Universität München:
Prof. Dr. med. Ruëff
|1.||Schmitz R, Thamm M, Ellert U, Kalcklösch M, Schlaud M: Verbreitung häufiger Allergien bei Kindern und Jugendlichen in Deutschland: Ergebnisse der KiGGS-Studie – Erste Folgebefragung (KiGGS Welle 1). Bundesgesundheitsblatt-Gesundheitsforschung-Gesundheitsschutz 2014; 57: 771–8 CrossRef MEDLINE|
|2.||Stocks SJ, McNamee R, van der Molen HF, et al.: Trends in incidence of occupational asthma, contact dermatitis, noise-induced hearing loss, carpal tunnel syndrome and upper limb musculoskeletal disorders in European countries from 2000 to 2012. Occup Environ Med 2015; 72: 294–303 CrossRef MEDLINE|
|3.||Gautrin D, Ghezzo H, Infante-Rivard C, Malo JL: Host determinants for the development of allergy in apprentices exposed to laboratory animals. Eur Respir J 2002; 19: 96–103 CrossRef|
|4.||Funke U, Fartasch M, Diepgen TL: Incidence of work-related hand eczema during apprenticeship: first results of a prospective cohort study in the car industry. Contact Dermatitis 2001; 44: 166–72 CrossRef|
|5.||Visser MJ, Verberk MM, van Dijk FJ, Bakker JG, Bos JD, Kezic S: Wet work and hand eczema in apprentice nurses; part I of a prospective cohort study. Contact Dermatitis 2014; 70: 44–55 CrossRef MEDLINE|
|6.||Kellberger J, Peters-Weist AS, Heinrich S, et al.: Predictors of work-related sensitisation, allergic rhinitis and asthma in early work life. Eur Respir J 2014; 44: 657–65 CrossRef MEDLINE|
|7.||Gui W, Wisnewski AV, Neamtiu I, et al.: Inception cohort study of workers exposed to toluene diisocyanate at a polyurethane foam factory: initial one-year follow-up. Am J Ind Med 2014; 57: 1207–15 CrossRef MEDLINE PubMed Central|
|8.||Elholm G, Schlunssen V, Doekes G, et al.: Become a farmer and avoid new allergic sensitization: adult farming exposures protect against new-onset atopic sensitization. J Allergy Clin Immunol 2013; 132: 1239–41 CrossRef MEDLINE|
|9.||Barakat-Haddad C, Elliott SJ, Pengelly D: Health impacts of air pollution: a life course approach for examining predictors of respiratory health in adulthood. Ann Epidemiol 2012; 22: 239–49 CrossRef MEDLINE|
|10.||Acouetey DS, Zmirou-Navier D, Avogbe PH, et al.: Genetic predictors of inflammation in the risk of occupational asthma in young apprentices. Ann Allergy Asthma Immunol 2013; 110: 423–8.e5 CrossRef MEDLINE|
|11.||Butland BK, Ghosh R, Strachan DP, Cullinan P, Jarvis D: Job choice and the influence of prior asthma and hay fever. Occup Environ Med 2011; 68: 494–501 CrossRef MEDLINE|
|12.||Wei J, Gerlich J, Vogelberg C, et al.: Do young adults with atopic dermatitis avoid harmful workplace exposure at their first job? A prospective cohort study. Int Arch Occup Environ Health 2016; 89: 397–406 CrossRef MEDLINE|
|13.||Kellberger J, Peters A, Heinrich S, et al.: Manifestation allergischer Krankheiten bei jungen Erwachsenen in Zusammenhang mit dem Eintritt in das Berufsleben. SOLAR II Abschlussbericht. Bundesministerium für Arbeit und Soziales 2011 PubMed Central|
|14.||Moscato G, Pala G, Boillat MA, et al.: EAACI position paper: prevention of work-related respiratory allergies among pre-apprentices or apprentices and young workers. Allergy 2011; 66: 1164–73 CrossRef MEDLINE|
|15.||Saab L, Gautrin D, Lavoue J, Suarthana E: Postapprenticeship isocyanate exposure and risk of work-related respiratory symptoms using an asthma- specific job exposure matrix, self-reported and expert-rated exposure estimates. J Occup Environ Med 2014; 56: 125–7 CrossRef MEDLINE|
|16.||Larese Filon F, Bochdanovits L, Capuzzo C, Cerchi R, Rui F: Ten |
years incidence of natural rubber latex sensitization and symptoms in a prospective cohort of health care workers using non-powdered latex gloves 2000–2009. Int Arch Occup Environ Health 2014; 87: 463–9 CrossRef MEDLINE
|17.||Mounchetrou IN, Monnet E, Laplante JJ, Dalphin JC, Thaon I: Predictors of early cessation of dairy farming in the French Doubs province: 12-year follow-up. Am J Ind Med 2012; 55: 136–42 CrossRef MEDLINE|
|18.||Dong S, Acouetey DS, Gueant-Rodriguez RM, et al.: Prevalence of IgE against neuromuscular blocking agents in hairdressers and bakers. Clin Exp Allergy 2013; 43: 1256–62 CrossRef MEDLINE|
|19.||Remen T, Acouetey DS, Paris C, et al.: Early incidence of occupational asthma is not accelerated by atopy in the bakery/pastry and hairdressing sectors. Int J Tuberc Lung Dis 2013; 17: 973–81 CrossRef MEDLINE|
|20.||Omland O, Hjort C, Pedersen OF, Miller MR, Sigsgaard T: New-onset asthma and the effect of environment and occupation among farming and nonfarming rural subjects. J Allergy Clin Immunol 2011; 128: 761–5 CrossRef MEDLINE|
|21.||Remen T, Acouetey DS, Paris C, Zmirou-Navier D: Diet, occupational exposure and early asthma incidence among bakers, pastry makers and hairdressers. BMC Public Health 2012; 12: 387 CrossRef MEDLINE PubMed Central|
|22.||Florentin A, Acouetey DS, Remen T, et al.: Exhaled nitric oxide and screening for occupational asthma in two at-risk sectors: bakery and hairdressing. Int J Tuberc Lung Dis 2014; 18: 744–50 CrossRef MEDLINE|
|23.||Graff P, Fredrikson M, Jonsson P, Flodin U: Non-sensitising air pollution at workplaces and adult-onset asthma in the beginning of this millennium. Int Arch Occup Environ Health 2011; 84: 797–804 CrossRef MEDLINE|
|24.||Fernández RP, Díez Jde M, Alvarez-Perea A, Tapia PM, García RJ, Gómez-Piñán VS: Risk factors for asthma onset between the ages of 12 and 40. Results of the FENASMA study. Arch Bronconeumol 2011; 47: 433–40 CrossRef MEDLINE|
|25.||Walusiak J, Hanke W, Gorski P, Palczynski C: Respiratory allergy in apprentice bakers: do occupational allergies follow the allergic march? Allergy 2004; 59: 442–50 CrossRef MEDLINE|
|26.||Bregnhøj A, Menne T, Johansen JD, Sosted H: Prevention of hand eczema among Danish hairdressing apprentices: an intervention study. Occup Environ Med 2012; 69: 310–6 CrossRef MEDLINE|
|27.||Apfelbacher CJ, Radulescu M, Diepgen TL, Funke U: Occurrence and prognosis of hand eczema in the car industry: results from the PACO follow-up study (PACO II). Contact Dermatitis 2008; 58: 322–9 CrossRef MEDLINE|
|28.||Bauer A, Bartsch R, Hersmann C, et al.: Occupational hand dermatitis in food industry apprentices: results of a 3-year follow-up cohort study. Int Arch Occup Environ Health 2001; 74: 437–42 CrossRef MEDLINE|
|29.||Gautrin D, Ghezzo H, Infante-Rivard C, Malo JL: Natural history of sensitization, symptoms and occupational diseases in apprentices exposed to laboratory animals. Eur Respir J 2001; 17: 904–8 CrossRef|
|30.||Ochmann U, Nowak D: Wann soll der Pneumologe an ein Berufsasthma denken? Pneumologe 2015; 12: 292–9 CrossRef|
|31.||Krop EJ, Heederik DJ, Lutter R, et al.: Associations between pre-employment immunologic and airway mucosal factors and the development of occupational allergy. J Allergy Clin Immunol 2009; 123: 694–700 CrossRef MEDLINE|
|32.||Gautrin D, Ghezzo H, Infante-Rivard C, et al.: Long-term outcomes in a prospective cohort of apprentices exposed to high-molecular-weight agents. Am J Respir Crit Care Med 2008; 177: 871–9 CrossRef MEDLINE|
|33.||Rodier F, Gautrin D, Ghezzo H, Malo JL: Incidence of occupational rhinoconjunctivitis and risk factors in animal-health apprentices. J Allergy Clin Immunol 2003; 112: 1105–11 CrossRef MEDLINE|
|34.||de Meer G, Postma DS, Heederik D: Bronchial responsiveness to adenosine-5’-monophosphate and methacholine as predictors for nasal symptoms due to newly introduced allergens. A follow-up study among laboratory animal workers and bakery apprentices. Clin Exp Allergy 2003; 33: 789–94 CrossRef MEDLINE|
|35.||Gautrin D, Infante-Rivard C, Ghezzo H, Malo JL: Incidence and host determinants of probable occupational asthma in apprentices exposed to laboratory animals. Am J Respir Crit Care Med 2001; 163: 899–904 CrossRef MEDLINE|
|36.||Archambault S, Malo JL, Infante-Rivard C, Ghezzo H, Gautrin D: Incidence of sensitization, symptoms, and probable occupational rhinoconjunctivitis and asthma in apprentices starting exposure to latex. J Allergy Clin Immunol 2001; 107: 921–3 CrossRef MEDLINE|
|37.||Gautrin D, Ghezzo H, Infante-Rivard C, Malo JL: Incidence and determinants of IgE-mediated sensitization in apprentices. A prospective study. Am J Respir Crit Care Med 2000; 162: 1222–8 CrossRef MEDLINE|
|38.||Gautrin D, Ghezzo H, Infante-Rivard C, Malo JL: Incidence and host determinants of work-related rhinoconjunctivitis in apprentice pastry-makers. Allergy 2002; 57: 913–8 CrossRef|
|39.||Cullinan P, Cook A, Nieuwenhuijsen MJ, et al.: Allergen and dust exposure as determinants of work-related symptoms and sensitization in a cohort of flour-exposed workers; a case-control analysis. Ann Occup Hyg 2001; 45: 97–103 CrossRef CrossRef|
|40.||Suarthana E, Heederik D, Ghezzo H, Malo JL, Kennedy SM, Gautrin D: Risks for the development of outcomes related to occupational allergies: an application of the asthma-specific job exposure matrix compared with self-reports and investigator scores on job-training-related exposure. Occup Environ Med 2009; 66: 256–63 CrossRef MEDLINE|
|e1.||Statistisches Bundesamt: Bildung und Kultur: Berufliche Bildung 2014. In: Statistisches Bundesamt, (ed.). Wiesbaden: Statistisches Bundesamt 2015.|
|e2.||Labrecque M, Malo JL, Alaoui KM, Rabhi K: Medical surveillance programme for diisocyanate exposure. Occup Environ Med 2011; 68: 302–7 CrossRef MEDLINE|
|e3.||Toren K, Blanc PD: Asthma caused by occupational exposures is common—A systematic analysis of estimates of the population-attributable fraction. BMC Pulm Med 2009; 9: 7 CrossRef MEDLINE PubMed Central|
|e4.||Cassidy LD, Molenaar DM, Hathaway JA, et al.: Trends in pulmonary function and prevalence of asthma in hexamethylene diisocyanate workers during a 19-year period. J Occup Environ Med 2010; 52: 988–94 CrossRef MEDLINE|
|e5.||Elholm G, Omland O, Schlunssen V, Hjort C, Basinas I, Sigsgaard T: The cohort of young Danish farmers—a longitudinal study of the health effects of farming exposure. Clin Epidemiol 2010; 2: 45–50 MEDLINE PubMed Central|
|e6.||Renstrom A, Malmberg P, Larsson K, Sundblad BM, Larsson PH: Prospective study of laboratory-animal allergy: factors predisposing to sensitization and development of allergic symptoms. Allergy 1994; 49: 548–52 CrossRef|
|e7.||Suarthana E, Malo JL, Heederik D, Ghezzo H, L’Archeveque J, Gautrin D: Which tools best predict the incidence of work-related sensitisation and symptoms. Occup Environ Med 2009; 66: 111–7 MEDLINE|
|e8.||Iwatsubo Y, Matrat M, Brochard P, et al.: Healthy worker effect and changes in respiratory symptoms and lung function in hairdressing apprentices. Occup Environ Med 2003; 60: 831–40 CrossRef MEDLINE PubMed Central|
|e9.||Sicherheit und Gesundheit bei der Arbeit 2014 – Unfallverhütungsbericht Arbeit. 2. Edition. Dortmund: Bundesanstalt für Arbeitsschutz und Arbeitsmedizin 2016.|
|e10.||Riu E, Dressel H, Windstetter D, et al.: First months of employment and new onset of rhinitis in adolescents. Eur Respir J 2007; 30: 549–55 CrossRef MEDLINE|
|e11.||Cullinan P, Cook A, Gordon S, et al.: Allergen exposure, atopy and smoking as determinants of allergy to rats in a cohort of laboratory employees. Eur Respir J 1999; 13: 1139–43 CrossRef MEDLINE|
|e12.||Nguyen B, Ghezzo H, Malo JL, Gautrin D: Time course of onset of sensitization to common and occupational inhalants in apprentices. J Allergy Clin Immunol 2003; 111: 807–12 CrossRef|
|e13.||Walusiak J, Palczynski C, Hanke W, Wittczak T, Krakowiak A, Gorski P: The risk factors of occupational hypersensitivity in apprentice bakers -- the predictive value of atopy markers. Int Arch Occup Environ Health 2002; 75 (Suppl): 117–21 CrossRef MEDLINE|
|e14.||De Zotti R, Bovenzi M: Prospective study of work related respiratory symptoms in trainee bakers. Occup Environ Med 2000; 57: 58–61 CrossRef PubMed Central|
|e15.||Skjold T, Dahl R, Juhl B, Sigsgaard T: The incidence of respiratory symptoms and sensitisation in baker apprentices. Eur Respir J 2008; 32: 452–9 CrossRef MEDLINE|
|e16.||Brant A, Upchurch S, van Tongeren M, et al.: Detergent protease exposure and respiratory disease: case-referent analysis of a retrospective cohort. Occup Environ Med 2009; 66: 754–8 CrossRef MEDLINE|
|e17.||Berndt U, Hinnen U, Iliev D, Elsner P: Role of the atopy score and of single atopic features as risk factors for the development of hand eczema in trainee metal workers. Br J Dermatol 1999; 140: 922–4 CrossRef|
|e18.||Schmid K, Broding HC, Uter W, Drexler H: Transepidermal water loss and incidence of hand dermatitis in a prospectively followed cohort of apprentice nurses. Contact Dermatitis 2005; 52: 247–53 CrossRef MEDLINE|
|e19.||Loerbroks A, Bosch JA, Douwes J, Angerer P, Li J: Job insecurity is associated with adult asthma in Germany during Europe’s recent economic crisis: a prospective cohort study. J Epidemiol Community Health 2014; 68: 1196–9 CrossRef MEDLINE|
|e20.||Radon K, Huemmer S, Dressel H, et al.: Do respiratory symptoms predict job choices in teenagers? Eur Respir J 2006; 27: 774–8.|
|e21.||Wiebert P, Svartengren M, Lindberg M, Hemmingsson T, Lundberg I, Nise G: Mortality, morbidity and occupational exposure to airway-irritating agents among men with a respiratory diagnosis in adolescence. Occup Environ Med 2008; 65: 120–5 CrossRef MEDLINE|
|e22.||Dumas O, Smit LA, Pin I, et al.: Do young adults with childhood asthma avoid occupational exposures at first hire? Eur Respir J 2011; 37: 1043–9|
|e23.||Bhinder S, Cicutto L, Abdel-Qadir HM, Tarlo SM: Perception of asthma as a factor in career choice among young adults with asthma. Can Respir J 2009; 16: e69–75 CrossRef MEDLINE PubMed Central|
|e24.||Brisman J, Meding B, Jarvholm B: Occurrence of self reported hand eczema in Swedish bakers. Occup Environ Med 1998; 55: 750–4 CrossRef|
|e25.||Diepgen TL: Epidemiological studies on the prevention of occupational contact dermatitis. Curr Probl Dermatol 1996; 25: 1–9 CrossRef|
|e26.||Uter W, Pfahlberg A, Gefeller O, Schwanitz HJ: Hand dermatitis in a prospectively-followed cohort of hairdressing apprentices: final results of the POSH study. Prevention of occupational skin disease in hairdressers. Contact Dermatitis 1999; 41: 280–6 CrossRef MEDLINE|
|e27.||Smit HA, van Rijssen A, Vandenbroucke JP, Coenraads PJ: Susceptibility to and incidence of hand dermatitis in a cohort of apprentice hairdressers and nurses. Scand J Work Environ Health 1994; 20: 113–21 CrossRef|
|e28.||Cullinan P, Tarlo S, Nemery B: The prevention of occupational asthma. Eur Respir J 2003; 22: 853–60 CrossRef|
|e29.||Slovak AJ, Hill RN: Does atopy have any predictive value for laboratory animal allergy? A comparison of different concepts of atopy. Br J Ind Med 1987; 44: 129–32 MEDLINE PubMed Central|
|e30.||Monso E, Malo JL, Infante-Rivard C, et al.: Individual characteristics and quitting in apprentices exposed to high-molecular-weight agents. Am J Respir Crit Care Med 2000; 161: 1508–12 CrossRef MEDLINE|
|e31.||Gerth van Wijk R, Patiwael JA, de Jong NW, de Groot H, Burdorf A: Occupational rhinitis in bell pepper greenhouse workers: determinants of leaving work and the effects of subsequent allergen avoidance on health-related quality of life. Allergy 2011; 66: 903–8 CrossRef MEDLINE|
|e32.||Nicholson PJ, Newman Taylor AJ, Oliver P, Cathcart M: Current best practice for the health surveillance of enzyme workers in the soap and detergent industry. Occup Med (Lond) 2001; 51: 81–92 CrossRef|
|e33.||Meijster T, van Duuren-Stuurman B, Heederik D, et al.: Cost-benefit analysis in occupational health: a comparison of intervention scenarios for occupational asthma and rhinitis among bakery workers. Occup Environ Med 2011; 68: 739–45 CrossRef CrossRef MEDLINE|
|e34.||Jones M, Schofield S, Jeal H, Cullinan P: Respiratory protective equipment reduces occurrence of sensitization to laboratory animals. Occup Med (Lond) 2014; 64: 104–8 CrossRef MEDLINE|
|e35.||Schurer NY, Klippel U, Schwanitz HJ: Secondary individual prevention of hand dermatitis in geriatric nurses. Int Arch Occup Environ Health 2005; 78: 149–57 CrossRef MEDLINE|
|e36.||Dressel H, Gross C, de la Motte D, Sultz J, Jorres RA, Nowak D: Educational intervention in farmers with occupational asthma: long-term effect on exhaled nitric oxide. J Investig Allergol Clin Immunol 2009; 19: 49–53 MEDLINE|
|e37.||Wengenroth L, Hege I, Förderreuther K, et al.: Promoting occupational health in secondary schools through virtual patients. Computers & Education 2010; 55: 1443–8 CrossRef|
|e38.||Bauer A, Kelterer D, Bartsch R, et al.: Skin protection in bakers’ apprentices. Contact Dermatitis 2002; 46: 81–5 CrossRef MEDLINE|
|e39.||Kutting B, Weistenhofer W, Baumeister T, Uter W, Drexler H: Current acceptance and implementation of preventive strategies for occupational hand eczema in 1355 metalworkers in Germany. Br J Dermatol 2009; 161: 390–6 CrossRef MEDLINE|
|e40.||Di Giampaolo L, Cavallucci E, Braga M, et al.: The persistence of allergen exposure favors pulmonary function decline in workers with allergic occupational asthma. Int Arch Occup Environ Health 2012; 85: 181–8 CrossRef MEDLINE|
|e41.||Vandenplas O, Dressel H, Wilken D, et al.: Management of occupational asthma: cessation or reduction of exposure? A systematic review of available evidence. Eur Respir J 2011; 38: 804–11 CrossRef MEDLINE|
|e42.||Talini D, Novelli F, Bacci E, et al.: Mild improvement in symptoms and pulmonary function in a long-term follow-up of patients with toluene diisocyanate-induced asthma. Int Arch Allergy Immunol 2013; 161: 189–94 CrossRef MEDLINE|
|e43.||Talini D, Novelli F, Melosini L, et al.: May the reduction of expo-sure to specific sensitizers be an alternative to work cessation in occupational asthma? Results from a follow-up study. Int Arch Allergy Immunol 2012; 157: 186–93 CrossRef MEDLINE|
|e44.||Muñoz X, Viladrich M, Manso L, et al.: Evolution of occupational asthma: does cessation of exposure really improve prognosis? Respir Med 2014; 108: 1363–70.|
|e45.||Johansen JD, Aalto-Korte K, Agner T, et al.: European Society of Contact Dermatitis guideline for diagnostic patch testing— recommendations on best practice. Contact Dermatitis 2015; 73: 195–221 CrossRef MEDLINE|
|e46.||Schnuch A, Aberer W, Agathos M, et al.: Durchführung des Epikutantests mit Kontakt-Allergenen. J Dtsch Dermatol Ges 2008; 6: 770–5 CrossRef CrossRef CrossRef MEDLINE|
|e47.||Gautrin D, Infante-Rivard C, Dao TV, Magnan-Larose M, Desjardins D, Malo JL: Specific IgE-dependent sensitization, atopy, and bronchial hyperresponsiveness in apprentices starting exposure to protein-derived agents. Am J Respir Crit Care Med 1997; 155: 1841–7 CrossRef MEDLINE|
|e48.||Schardt C, Adams MB, Owens T, Keitz S, Fontelo P: Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Med Inform Decis Mak 2007; 7: 16 CrossRef MEDLINE PubMed Central|
|e49.||Uter W, Schwanitz HJ, Pfahlberg A, Gefeller O: Atopic signs and symptoms: assessing the ’atopy score’ concept. Dermatology 2001; 202: 4–8 CrossRef|
|e50.||Berndt U, Hinnen U, Iliev D, Elsner P: Is occupational irritant contact dermatitis predictable by cutaneous bioengineering methods? Results of the Swiss Metalworkers’ Eczema Study (PROMETES). Dermatology 1999; 198: 351–4 CrossRef|
|e51.||Bonin S, Larese FF, Trevisan G, et al.: Gene expression changes in peripheral blood mononuclear cells in occupational exposure to nickel. Exp Dermatol 2011; 20: 147–8 CrossRef MEDLINE|
|e52.||Cavallo D, Ursini CL, Setini A, Chianese C, Cristaudo A, Iavicoli S: DNA damage and TNFalpha cytokine production in hairdressers with contact dermatitis. Contact Dermatitis 2005; 53: 125–9 CrossRef MEDLINE|
|e53.||de Jongh CM, John SM, Bruynzeel DP, et al.: Cytokine gene polymorphisms and susceptibility to chronic irritant contact dermatitis. Contact Dermatitis 2008; 58: 269–77 CrossRef MEDLINE|
|e54.||Herxheimer H: The skin sensitivity to flour of baker’s apprentices. A final report of a long term investigation. Acta Allergol 1973; 28: 42–9 CrossRef MEDLINE|
|e55.||Holm JO: An epidemiological study of hand eczema. VI. A follow-up of hairdresser trainees, with the focus on various health complaints. Acta Derm Venereol Suppl (Stockh) 1994; 187: 26–7.|
|e56.||Houle MC, Holness DL, Dekoven J, Skotnicki S: Additive value of patch testing custom epoxy materials from the workplace at the occupational disease specialty clinic in Toronto. Dermatitis 2012; 23: 214–9 CrossRef MEDLINE|
|e57.||John SM, Uter W, Schwanitz HJ: Relevance of multiparametric skin bioengineering in a prospectively-followed cohort of junior hairdressers. Contact Dermatitis 2000; 43: 161–8 CrossRef|
|e58.||Kienlein-Kletschka B: [Work in a humid environment as a conditioning factor in the genesis of occupation-induced dermatoses]. Derm Beruf Umwelt 1984; 32: 14–6 MEDLINE|
|e59.||Lindemayr H: [Hairdresser eczema and nickel allergy]. Hautarzt 1984; 35: 292–7 MEDLINE|
|e60.||Budnik LT, Preisser AM, Permentier H, Baur X: Is specific IgE antibody analysis feasible for the diagnosis of methylenediphenyl diisocyanate-induced occupational asthma? Int Arch Occup Environ Health 2013; 86: 417–30 CrossRef MEDLINE PubMed Central|
|e61.||Dimich-Ward H, Beking K, DyBuncio A, et al.: Occupational exposure influences on gender differences in respiratory health. Lung 2012; 190: 147–54 CrossRef MEDLINE|
|e62.||Fishwick D, Harris-Roberts J, Robinson E, et al.: Impact of worker education on respiratory symptoms and sensitization in bakeries. Occup Med (Lond) 2011; 61: 321–7 CrossRef MEDLINE|
|e63.||Lysdal SH, Mosbech H, Johansen JD, Sosted H: Asthma and respiratory symptoms among hairdressers in Denmark: results from a register based questionnaire study. Am J Ind Med 2014; 57: 1368–76 CrossRef MEDLINE|
|e64.||Rihs HP, Lotz A, Rueff F, Landt O, Bruning T, Raulf-Heimsoth M: Impact of interleukin-13 and -18 promoter polymorphisms in health care workers with natural rubber latex allergy. |
J Toxicol Environ Health A 2012; 75: 515–24 CrossRef MEDLINE
|e65.||Suarthana E, Shen A, Henneberger PK, et al.: Post-hire asthma among insect-rearing workers. J Occup Environ Med 2012; 54: 310–7 CrossRef MEDLINE|
|e66.||Vandenplas O, D’Alpaos V, Evrard G, Jamart J: Incidence of severe asthmatic reactions after challenge exposure to occupational agents. Chest 2013; 143: 1261–8 CrossRef MEDLINE|
|e67.||Hougaard MG, Winther L, Sosted H, Zachariae C, Johansen JD: Occupational skin diseases in hairdressing apprentices— has anything changed? Contact Dermatitis 2015; 72: |
40–6. CrossRef MEDLINE
|e68.||Bryld LE, Hindsberger C, Kyvik KO, Agner T, Menne T: Risk factors influencing the development of hand eczema in a population-based twin sample. Br J Dermatol 2003; 149: 1214–20 CrossRef|
|e69.||Aalto-Korte K, Suuronen K, Kuuliala O, Henriks-Eckerman ML, Jolanki R: Screening occupational contact allergy to bisphenol F epoxy resin. Contact Dermatitis 2014; 71: 138–44 CrossRef MEDLINE|
|e70.||Bregnbak D, Thyssen JP, Zachariae C, Johansen JD: Characteristics of chromium-allergic dermatitis patients prior to regulatory intervention for chromium in leather: a questionnaire study. Contact Dermatitis 2014; 71: 338–47 CrossRef MEDLINE|
|e71.||Bauer A, Kelterer D, Bartsch R, et al.: Prevention of hand dermatitis in bakers’ apprentices: different efficacy of skin protection measures and UVB hardening. Int Arch Occup Environ Health 2002; 75: 491–9 CrossRef MEDLINE|
|e72.||Broding HC, Frank P, Hoffmeyer F, Bunger J: Course of occupational asthma depending on the duration of workplace exposure to allergens—a retrospective cohort study in bakers and farmers. Ann Agric Environ Med 2011; 18: 35–40 MEDLINE|
|e73.||Ghosh RE, Cullinan P, Fishwick D, et al.: Asthma and occupation in the 1958 birth cohort. Thorax 2013; 68: 365–71 CrossRef MEDLINE|
|e74.||Lindstrom I, Suojalehto H, Pallasaho P, et al.: Middle-aged men with asthma since youth: the impact of work on asthma. J Occup Environ Med 2013; 55: 917–23 CrossRef MEDLINE|
|e75.||Mirabelli MC, London SJ, Charles LE, Pompeii LA, Wagenknecht LE: Occupation and three-year incidence of respiratory symptoms and lung function decline: the ARIC Study. Respir Res 2012; 13: 24 CrossRef MEDLINE PubMed Central|
|e76.||Rask-Andersen A: Asthma increase among farmers: |
a 12-year follow-up. Ups J Med Sci 2011; 116: 60–71 CrossRef MEDLINE PubMed Central
|e77.||Smit LA, Strachan DP, Vermeulen R, et al.: Human leukocyte antigen class II variants and adult-onset asthma: does occupational allergen exposure play a role? Eur Respir J 2014; 44: 1234–42.|
|e78.||Nyren M, Lindberg M, Stenberg B, Svensson M, Svensson A, Meding B: Influence of childhood atopic dermatitis on future worklife. Scand J Work Environ Health 2005; 31: 474–8 CrossRef|
|e79.||Lind ML, Albin M, Brisman J, et al.: Incidence of hand eczema in female Swedish hairdressers. Occup Environ Med 2007; 64: 191–5 CrossRef MEDLINE PubMed Central|
|e80.||Mortz CG, Bindslev-Jensen C, Andersen KE: Hand eczema in The Odense Adolescence Cohort Study on Atopic Diseases and Dermatitis (TOACS): prevalence, incidence and risk factors from adolescence to adulthood. Br J Dermatol 2014; 171: 313–23 CrossRef MEDLINE|
|e81.||Apfelbacher CJ, Funke U, Radulescu M, Diepgen TL: Determinants of current hand eczema: results from case-control studies nested in the PACO follow-up study (PACO II). Contact Dermatitis 2010; 62: 363–70 CrossRef MEDLINE|
|e82.||Majoie IM, von Blomberg BM, Bruynzeel DP: Development of hand eczema in junior hairdressers: an 8-year follow-up study. Contact Dermatitis 1996; 34: 243–7 CrossRef|
|e83.||Uter W, Pfahlberg A, Gefeller O, Schwanitz HJ: Hand eczema in a prospectively-followed cohort of office-workers. Contact Dermatitis 1998; 38: 83–9.|
|e84.||Borelli S, Moormann J, Dungemann H, Manok M: [Results of a 4-year serial test on apprentices of the hairdresser profession]. Berufsdermatosen 1965; 13: 216–38.|
|e85.||Hornstein OP, Baurle G, Kienlein-Kletschka B: [Prospective study of the importance of constitutional parameters in the development of eczema in hairdressers and construction workers]. Derm Beruf Umwelt 1985; 33: 43–9 MEDLINE|
|e86.||Reichenberger M: [Dyshidrosis as a pacemaker for occupational dermatoses]. Berufsdermatosen 1975; 23: 127–30 MEDLINE|
|e87.||Uter W, Gefeller O, Schwanitz HJ: [Early onset irritant skin damage in apprentice hair dressers]. Hautarzt 1995; 46: 771–8 MEDLINE|
|e88.||Uter W, Gefeller O, Schwanitz HJ: Occupational dermatitis in hairdressing apprentices. Early-onset irritant skin damage. Curr Probl Dermatol 1995; 23: 49–55 CrossRef MEDLINE|
|e89.||Uter W, Pfahlberg A, Gefeller O, Schwanitz HJ: Risk of hand dermatitis among hairdressers versus office workers. Scand J Work Environ Health 1999; 25: 450–6 CrossRef|
|e90.||Hoy RF, Burgess JA, Benke G, et al.: Occupational exposures and the development of new-onset asthma: a population-based cohort study from the ages of 13 to 44 years. J Occup Environ Med 2013; 55: 235–9 CrossRef MEDLINE|
|e91.||Uter W, Pfahlberg A, Gefeller O, Schwanitz HJ: Prevalence and incidence of hand dermatitis in hairdressing apprentices: results of the POSH study. Prevention of occupational skin disease in hairdressers. Int Arch Occup Environ Health 1998; 71: 487–92 CrossRef MEDLINE|
|e92.||Bauer A, Bartsch R, Stadeler M, et al.: Development of occupational skin diseases during vocational training in baker and confectioner apprentices: a follow-up study. Contact Dermatitis 1998; 39: 307–11 CrossRef MEDLINE|
|e93.||Gan WH, Low R, Koh D: Dermatological conditions in military conscripts. Occup Med (Lond) 2013; 63: 435–8 CrossRef MEDLINE|
|e94.||Schafer T, Bohler E, Ruhdorfer S, et al.: Epidemiology of contact allergy in adults. Allergy 2001; 56: 1192–6 CrossRef MEDLINE|
|e95.||van der Burg CK, Bruynzeel DP, Vreeburg KJ, von Blomberg BM, Scheper RJ: Hand eczema in hairdressers and nurses: a prospective study. I. Evaluation of atopy and nickel hypersensitivity at the start of apprenticeship. Contact Dermatitis 1986; 14: 275–9 CrossRef MEDLINE|
|e96.||Radon K, Riu E, Dressel H, et al.: Adolescents’ jobs and the course of dermatitis symptoms throughout puberty. Scand J Work Environ Health 2006; 32: 132–7 CrossRef MEDLINE|
|e97.||de Jongh CM, Khrenova L, Verberk MM, et al.: Loss-of-function polymorphisms in the filaggrin gene are associated with an increased susceptibility to chronic irritant contact dermatitis: a case-control study. Br J Dermatol 2008; 159: 621–7 CrossRef MEDLINE|
|e98.||Landeck L, Visser M, Kezic S, John SM: Impact of tumour necrosis factor-alpha polymorphisms on irritant contact dermatitis. Contact Dermatitis 2012; 66: 221–7 CrossRef MEDLINE|
|e99.||Dumas O, Varraso R, Zock JP, et al.: Asthma history, job type and job changes among US nurses. Occup Environ Med 2015; 72: 482–8 CrossRef MEDLINE PubMed Central|
|e100.||Bregnhoj A, Sosted H, Menne T, Johansen JD: Healthy worker effect in hairdressing apprentices. Contact Dermatitis 2011; 64: 80–4 CrossRef MEDLINE|
|e101.||Kronholm Diab K, Jonsson BA, Axmon A, Nielsen J: Work-related airway symptoms, nasal reactivity and health-related quality of life in female hairdressers: a follow-up study during exposure. Int Arch Occup Environ Health 2014; 87: 61–71 CrossRef MEDLINE PubMed Central|
|e102.||Bregnhoj A, Sosted H, Menne T, Johansen JD: Exposures and reactions to allergens among hairdressing apprentices and matched controls. Contact Dermatitis 2011; 64: 85–9 CrossRef MEDLINE|
|e103.||Meding B, Lindahl G, Alderling M, Wrangsjo K, Anveden Berglind I: Is skin exposure to water mainly occupational or nonoccupational? A population-based study. Br J Dermatol 2013; 168: |
1281–6 CrossRef MEDLINE
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